Ophthalmology and Optometry Coding Alert

Billing for additional services during a global surgery period is always tricky, but now you can expect special scrutiny for modifier 79 claims.

After the Office of Inspector General (OIG) got wind of fraudulent surgery billing with modifier 79 (Unrelated procedure or service by the same physician during the postoperative period), CMS contractors have been on the hunt for modifier 79 abuse.

Action plan: Implement our expert tips below to keepyour 79 claims clean.

The starting point for clean modifier 79 claims is not breaching the global surgical billing concept. Once you understand the global package rules, you'll know when you have an exception that warrants an additional claim with an appropriate modifier.

Know what's included: The global package includes the preoperative visit the day before surgery, intraoperative services, postsurgical complications handled in the office, and postoperative visits during the global period.

The global package also includes post-surgical pain management services by the surgeon, and miscellaneous services such as dressing changes, suture removal, and staples, according to Donna Pisani, provider outreach and education consultant with National Government Services (NGS) during a global surgery conference call. NGS is a Medicare payer in 25 states.

If your ophthalmic surgeon performs a service duringthe global period that the "package" doesn't include, you can bill separately for the additional procedure -- but you'll have to use a modifier.

Key to 79: You'll know that 79 is the correct modifier if the second procedure is for an unrelated condition during the global period of the first surgery. In other words, if the same surgeon must perform a separate, unrelated procedure for an unexpected medical condition during the global period of a previous procedure, you should append modifier 79 to any subsequent procedural code(s).

Tip: "If the second procedure takes place on a different body part (opposite eye in this case), 79 is usually the correct modifier," says Joseph A. Lamm, office manager for Stark County Surgeons in Massillon, Ohio.

Another clue that you should use modifier 79 is if the surgeon links a second procedure to a totally different diagnosis and does not mention a "complication" or that the second procedure is staged or related to the first, according to Lamm.

Example: The ophthalmologist performs cataract extraction with insertion of an intraocular lens (66984, Extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique). Following the procedure, the patient develops a retinal detachment that requires a repair (67105, Repair of retinal detachment, one or more sessions; photocoagulation, with or without drainage of subretinal fluid).

A physician in the group practice is a retinal specialist, and the patient is referred for evaluation of the detachment and for the repair.

If a consultation was requested by the primary provider from the subspecialist, a consultation service, 99241-99245 (Office consultation for a new or established patient ...), with modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) appended to show that the consultation is unrelated to the cataract extraction.

Keep in mind: Medicare will no longer reimburse for consultation codes effective January 1, 2010. Therefore, you should assign a new or established patient E/M code. For the surgical procedure, report codes 67105-79, plus the LT (Left side) or RT (Right side) modifier. Although the patient did not have a detachment prior to the first surgery, Medicare does not consider the condition to be related to the cataract surgery because it is not a normal course of treatment following cataract surgery. Not every patient who undergoes cataract surgery develops a retinal detachment, so the two conditions are not related in Medicare's eyes.

Thanks to abusive practices of some providers who used modifier 79 to bypass surgical bundling rules, the OIG "has asked all contract-ors to look at codes with modifier 79," Pisani says.

Loophole: Although CMS established pre-payment edits to detect when providers unbundle services from the global surgical package, services billed with modifier 79 were excluded from those pre-payment edits. That's why CMS has instructed contractors to "strengthen program safeguards" against fraudulent modifier 79 claims.

"Be aware if you're using modifier 79 that you're using it appropriately, and your records reflect medical necessity in the documentation," Pisani notes.

Resource: To read the CMS instruction on modifier 79 scrutiny, go to www.cms.hhs.gov/transmittals/downloads/R442OTN.pdf

Unrelated conditions aren't the only reason your surgeon might perform a separate procedure during a global surgical period. If the second procedure is not unrelated to the initial surgery, you'll have to turn to modifiers other than 79:

• Identify planned or staged: Call on modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) when the surgeon performs a secondary surgery during the post-op period of another surgery and the subsequent procedure was planned or staged, Pisani notes.

• Distinguish related but not planned: Modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) applies to the service when the physician has to unexpectedly return the patient to the operating room (OR) for a complication related to the procedure during the postoperative period, Pisani says.

Remember: Medicare will only pay for treating a complication during the surgical global period if treatment requires a return to the operating room.